Provider Demographics
NPI:1487641817
Name:HAYNIE, GARY DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DONALD
Last Name:HAYNIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11247
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58106-1247
Mailing Address - Country:US
Mailing Address - Phone:701-277-4699
Mailing Address - Fax:701-277-8357
Practice Address - Street 1:4642 AMBER VALLEY PKWY S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8612
Practice Address - Country:US
Practice Address - Phone:701-277-4699
Practice Address - Fax:701-277-8357
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND6710207W00000X
MN36803207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11166Medicaid
ND11166Medicaid